HEAD AND NECK INFECTIONS








Bell palsy

Overview

  • Epidemiology - Bell palsy affects about 1 in 60 - 70 people over a lifetime. It can occur at any age, but the risk is highest in adults, and the median age of onset is 40 years. It is the most common cause of unilateral facial weakness, accounting for 60 - 75% of all cases.
  • Pathology - Bell palsy is believed to occur from inflammation of the facial nerve at the geniculate ganglion. The cause of inflammation has not been fully elucidated, but herpes simplex virus has been detected in some patients, making it a possible etiology.
  • Symptoms/diagnosis - Bell palsy presents with weakness or complete paralysis of the muscles on one side of the face that develops over 1 - 3 days. Maximal weakness usually occurs within 3 days and almost always within 1 week. Bell palsy is a peripheral nerve condition, and when evaluating patients, it is important to distinguish it from central nerve conditions, particularly acute stroke. Bell palsy differs from a stroke in that it affects both the upper and lower parts of the face, and a stroke only affects the lower part of the face. Patients with Bell palsy will not be able to raise their forehead or close their eye on the affected side, whereas patients with a stroke can. Other conditions that can affect the facial nerve include multiple sclerosis, Ramsay Hunt syndrome (herpes zoster affecting cranial nerve 7), facial neuroma, myasthenia gravis, Lyme disease, sarcoidosis, parotid tumors, Guillain-Barré syndrome, and CNS tumors.
  • Recovery - Most patients with Bell palsy have complete recovery of facial motor function, but up to 30% of patients may have a residual deficit. In one study (see studies below), 64.7% of untreated patients had full recovery at 3 months, and 85.2% had full recovery at 9 months. Recurrences of Bell palsy are rare.
  • Treatment - Corticosteroids have been shown to improve outcomes in some studies, while antivirals have not shown a consistent benefit. Decompression surgery is rarely performed, and its effects have not been evaluated in well-done trials. If it is considered, it should be performed within 14 days of the onset of paralysis. [2,24,25]

Treatment (AAN 2012)

For patients with new-onset Bell palsy, the following treatments are recommended:
  • NOTE: "New-onset" is typically considered to be within 1 week of symptom onset. A benefit beyond this period has not been ruled out.
  • Corticosteroids - oral steroids should be offered to increase the probability of facial nerve recovery. The guideline does not give specific dosage recommendations. Trials cited in the recommendation used prednisone-equivalent doses of 50 - 60 mg a day for 5 - 10 days. ($)
  • Antivirals - for patients with new-onset Bell palsy, antivirals (in addition to steroids) might be offered to increase the probability of facial nerve recovery. Patients offered antivirals should be counseled that a benefit from antivirals has not been established, and if there is one, it is likely modest. The guideline does not recommend a specific drug or dosage. Trials cited in the recommendation used one of the following:
    • Acyclovir 400 mg five times daily for 10 days [2] ($)
    • Valacyclovir 1000 mg three times a day for 7 days [14] ($)

Studies

Prednisolone vs Acyclovir vs Both for Bell's Palsy, NEJM (2007) [PubMed abstract]
  • Design: Randomized, 2 X 2 factorial design, placebo-controlled trial (N=551 | length = 9 months) in patients with Bell's palsy and symptom onset within 72 hours
  • Treatment: Prednisolone 25 mg twice daily, Acyclovir 400 mg 5 times daily, Both drugs, or Placebo. All drugs were given for 10 days.
  • Primary outcome: Recovery of facial function, as rated on the House–Brackmann scale
  • Results:
    • Primary outcome (3 months): Prednisolone - 83%, Placebo - 63.6% (p <0.001) | Acyclovir - 71.2%, Placebo - 75.7% (p=0.50) | Both drugs - 79.7% | Double placebo - 64.7%
    • Primary outcome (9 months): Prednisolone - 94.4%, Placebo - 81.6% (p <0.001) | Acyclovir - 85.4%, Placebo - 90.8% (p=0.10) | Both drugs - 92.7% | Double placebo - 85.2%
    • There was no significant interaction between acyclovir and prednisolone
  • Findings: In patients with Bell’s palsy, early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months. There is no evidence of a benefit of acyclovir given alone or an additional benefit of acyclovir in combination with prednisolone.

Conjunctivitis (pink eye)

Overview

  • Children are more likely to have bacterial conjunctivitis (up to 70% of cases), and adults are more likely to have a viral etiology (up to 80% of cases)
  • No clinical feature differentiates between bacterial and viral conjunctivitis with high certainty. Findings that are more consistent with viral conjunctivitis include pharyngitis, preauricular lymphadenopathy, and contact with an individual that has pink eye. Bacterial conjunctivitis may be more likely if mucopurulent discharge or otitis media is present. Bacterial and viral conjunctivitis are typically self-limited and resolve without treatment; antibiotics may speed recovery of bacterial conjunctivitis.
  • No clinical evidence suggests superiority of one antibiotic over another
  • Neisseria gonorrhoeae and Chlamydia trachomatis infections require systemic therapy [4,5,27]

Treatment

Aminoglycosides
  • Gentamicin (Garamycin®)
    • Ointment: 1/2 inch 2 - 3 times a day for 1 week ($)
    • Solution: 1 - 2 drops every 4 hours for 1 week | severe infection: 1 - 2 drops every hour ($)
  • Tobramycin (Tobrex®)
    • Ointment: 1/2 inch 3 times a day for 1 week | severe infection: 1/2 inch every 3 - 4 hours ($)
    • Solution: 1 - 2 drops every 4 hours for 1 week | severe infection: 2 drops every hour ($)
Quinolones
  • Besifloxacin (Besivance®) suspension: 1 drop 3 times a day for 7 days ($$$)
  • Ciprofloxacin (Ciloxan®)
    • Ointment: 1/2 inch 3 times a day for 2 days, then 1/2 inch twice a day for 5 days ($$$)
    • Solution: 1 - 2 drops every 2 hours while awake for 2 days, then 1 - 2 drops every 4 hours while awake for 5 days ($)
  • Gatifloxacin (Zymaxid®) solution: 1 drop every 2 hours while awake, up to 8 times on Day 1, then 1 drop 2 - 4 times a day on Days 2 - 7 ($)
  • Levofloxacin (Quixin®) solution: 1 - 2 drops every 2 hours while awake, up to 8 times on Days 1 and 2, then 1 - 2 drops 4 times a day on Days 3 - 7 ($)
  • Moxifloxacin (Vigamox®) solution: 1 drop 3 times a day for 7 days ($)
  • Moxifloxacin (Moxeza®) solution: 1 drop 2 times a day for 7 days ($$$$)
  • Ofloxacin (Ocuflox®) solution: 1 - 2 drops every 2 - 4 hours while awake on Days 1 and 2, then 1 - 2 drops 4 times a day on Days 3 - 7 ($)
Macrolides
  • Azithromycin (Azasite®) solution: 1 drop twice daily on Days 1 and 2, then 1 drop daily on Days 3 - 7 ($$$)
  • Erythromycin ointment: 1 cm up to 6 times a day for 1 week ($)
Sulfa
  • Sulfacetamide (Bleph-10®) solution: 1 - 2 drops every 2 - 3 hours initially, then taper. Treat for 7 days. ($)
Other
  • Polymyxin B + trimethoprim (Polytrim®) solution: 1 drop every 3 hours (max of 6/day) for 7 - 10 days ($)




Otitis media (OM)

Overview

  • Epidemiology - otitis media (OM) is the most common childhood infection, with up to 75% of children experiencing an episode during the first 3 years of life. Of these children, half will have ≥ 3 episodes during the same period. The peak incidence of OM is between 6 and 18 months of age, and children who have their first episode before the age of one are at greater risk of recurrence. OM also occurs in adults and adolescents, but it is much less common in these age groups.
  • Pathology - the eustachian tube connects the middle ear to the nasopharynx (eustachian tube illustration), where it performs the following functions: (1) stabilization of the pressure gradient between the middle ear and the pharynx, (2) protects against ascending pathogens, (3) funnels debris and secretions back into the pharynx. Infections of the middle ear occur when the tube does not function properly, and young children are especially susceptible due to the following factors: (1) undeveloped tubes that are short and horizontal, (2) recurrent viral infections of the nasopharynx that inflame and disrupt the mucosa of the tubes, (3) immature immune systems, (4) large or swollen adenoids that block the end of the tubes. The most common pathogens in OM are S pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.
  • Symptoms / Physical exam - symptoms of OM include ear pain, fever, ear drainage, decreased appetite, irritability, vomiting, and diarrhea. In acute otitis media, the tympanic membrane has the following characteristics: (1) opaque with a red injection, (2) white or clear fluid present behind the TM, (3) bulging with reduced mobility, (4) perforation may be present. If a chronic effusion develops, the tympanic membrane may become retracted. Recurrent or chronic OM may cause hearing loss and affect speech development. (otitis media image) (retracted TM image) [22,23,26]

Ear tube recommendations

Indications for placement
  • AAP 2013 recommendations
    • Clinicians may offer tympanostomy tubes for recurrent acute OM (3 episodes in 6 months or 4 episodes in 1 year with 1 episode in the preceding 6 months) [7]

  • AAO-HNS 2013 recommendations
    • Middle ear effusion
      • Clinicians should offer bilateral tympanostomy tube insertion to children with bilateral effusion for 3 months or longer AND documented hearing difficulties
      • Clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral effusion for 3 months or longer AND symptoms that are likely attributable to effusions that include, but are not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life
    • Recurrent acute OM (3 episodes in 6 months or 4 episodes in 1 year with 1 episode in the preceding 6 months)
      • Clinicians should offer bilateral tympanostomy tube insertion to children with recurrent acute OM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy
      • Clinicians should not perform tympanostomy tube insertion in children with recurrent acute OM who do not have middle ear effusion in either ear at the time of assessment for tube candidacy [8]

Infection treatment
  • Ear drops are preferred over oral medications in otitis media with perforation and otitis media with ear tubes. See treatment regimens with ear tubes below.
  • Ototoxicity from aminoglycosides (neomycin, gentamicin, tobramycin) is controversial. There have been case reports of ototoxicity, but no definitive link has been established.
  • Cortisporin otic suspension is preferred over Cortisporin otic solution because it has a higher pH and may be less irritating

Follow-up and care
  • Most tubes stay in place for about 6 - 18 months before falling out on their own. Tubes that have not come out after 3 years may need to be removed.
  • The chance of a tube falling on the inside of the tympanic membrane is very low
  • Some children may develop a white patch or small depression on their tympanic membrane at the site where the tube was placed. These defects are benign.
  • Ear plugs are not routinely recommended during swimming because water does not usually go through the tubes. Situations where ear plugs may be beneficial include the following:
    • Swimming more than 6 feet under water
    • Swimming in lakes or non-chlorinated pools
    • Dunking head in a bathtub (soapy water has a lower surface tension than plain water)
    • Signs or symptoms of otitis media or otitis externa [7,8]

Treatment - Intact TM

Pediatric (AAP recommendations)
  • First-line
    • Note: Amoxicillin-clavulanate preparations with a 14:1 ratio of amoxicillin-clavulanate are less likely to cause diarrhea than preparations with a lower ratio
    • Amoxicillin - 80 - 90 mg/kg/day given in 2 divided doses for 5 - 10 days✝ ($)
    • Amoxicillin-clavulanate (Augmentin®) - 90 mg/kg/day of amoxicillin, with 6.4 mg/kg/day of clavulanate [amoxicillin to clavulanate ratio, 14:1] given in 2 divided doses) for 5 - 10 days✝ ($)
  • Penicillin-allergic
    • Note: Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to cross-react in penicillin-allergic patients because they differ significantly in chemical structure [7]
  • Other
    • Clindamycin - 30–40 mg/kg/day given in 3 divided doses for 5 - 10 days✝ ($$-$$$) [7]

  • ✝ Length of therapy
    • Age < 2 years: 10 days of therapy
    • Age 2 - 5 years: 7 days of therapy
    • Age ≥ 6 years: 5 - 7 days of therapy

Treatment - Ear tubes or perforated TM

First-line (FDA-approved)
  • Ofloxacin (Floxin otic®)
    • Ear tubes - Five drops instilled into the affected ear twice daily for ten days. Warm bottle first by holding in hand. The patient should lie with the affected ear upward, and then the drops should be instilled. The tragus should be pumped 4 times by pushing inward to facilitate penetration of the drops into the middle ear. This position should be maintained for five minutes.
    • Perforated TM - Ten drops instilled into the affected ear twice daily for fourteen days. Warm bottle first by holding in hand. The patient should lie with the affected ear upward, and then the drops should be instilled. The tragus should be pumped 4 times by pushing inward to facilitate penetration into the middle ear. This position should be maintained for five minutes. ($)
  • Ciprofloxacin and fluocinolone (Otovel®)
    • Ear tubes - Instill the contents of one single-dose vial (0.25 ml) into the affected ear canal twice daily (approximately every 12 hours) for 7 days. Warm the solution by holding the vial in the hand for 1 to 2 minutes. Lie with the affected ear upward. Pump the tragus four times. Maintain position for 1 minute. ($$$$)
  • Ciprofloxacin and dexamethasone (Ciprodex®)
    • Ear tubes - Four drops instilled into the affected ear twice daily for seven days. Warm bottle first by holding in hand. The tragus should be pumped 5 times by pushing inward to facilitate penetration of the drops into the middle ear. This position should be maintained for 60 seconds. ($$)
Other (not FDA-approved)
  • Cortisporin-TC® (colistin, neomycin, thonzonium, hydrocortisone) - otic suspension; 4 - 5 drops in affected ear 3 - 4 times a day. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 5 minutes to facilitate penetration of the drops into the ear canal. ($$$$)
  • Ophthalmic drops - gentamicin, tobramycin, and ciprofloxacin ophthalmic drops have been used. See conjunctivitis above. [9]

Studies

Tympanostomy Tubes vs Medical Management for Recurrent OM, NEJM (2021) [PubMed abstract]
  • Design: Randomized, controlled trial (N=250 | length = 2 years) in children 6 - 35 months with at least three episodes of acute otitis media within 6 months, or at least four episodes within 12 months
  • Treatment: Tympanostomy-tube placement (ear tubes) vs Medical management. In the tympanostomy group, OM was treated with ofloxacin drops followed by Augmentin if otorrhea persisted beyond 7 days. In the medical management group, OM was treated with 10 days of Augmentin followed by ceftriaxone if response was inadequate.
  • Primary outcome: Mean number of episodes of acute otitis media per child-year (rate) during the 2-year follow-up period in the intention-to-treat analysis
  • Results:
    • Primary outcome (average OM per child-year): Tympanostomy tubes - 1.48, Medical management - 1.56 (p=0.66)
    • Crossovers: 10% of subjects in the tympanostomy group did not receive tubes, and 45% of subjects in the medical management group received tubes
  • Findings: Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management.
Oral Steroids vs Placebo for OM with Effusion, Lancet (2018) [PubMed abstract]
  • Design: Randomized, placebo-controlled trial (N=389 | length = 5 weeks) in children aged 2-8 years with otitis media with effusion for at least 3 months and confirmed bilateral hearing loss
  • Treatment: Prednisolone 20 - 30 mg once daily for 7 days vs Placebo
  • Primary outcome: Audiometry-confirmed acceptable hearing at 5 weeks
  • Results:
    • Primary outcome: Prednisolone - 40%, Placebo - 33% (p=0.16)
  • Findings: Otitis media with effusion in children with documented hearing loss and attributable symptoms for at least 3 months has a high rate of spontaneous resolution. A short course of oral prednisolone is not an effective treatment for most children aged 2 – 8 years with persistent otitis media with effusion, but is well tolerated. One in 14 children might achieve improved hearing but not quality of life. Discussions about watchful waiting and other interventions will be supported by this evidence.
Five Days vs Ten Days of Augmentin for Acute OM, NEJM (2016) [PubMed abstract]
  • Design: Randomized, placebo-controlled trial (N=520 | length = mean of 4.2 months) in children 6 to 23 months of age with acute otitis media
  • Treatment: Augmentin 90 mg/6.4 mg/kg/day for 5 days vs 10 days
  • Primary outcome: Clinical failure
  • Results:
    • Primary outcome: Five days - 34%, Ten days - 16% (diff 17%, 95%CI [9 - 25])
  • Findings: Among children 6 to 23 months of age with acute otitis media, reduced-duration antimicrobial treatment resulted in less favorable outcomes than standard-duration treatment; in addition, neither the rate of adverse events nor the rate of emergence of antimicrobial resistance was lower with the shorter regimen

Otitis externa (swimmer's ear)

Treatment

  • Acetic acid solution (Vosol®) - insert a wick of cotton saturated with acetic acid into the ear canal. Keep the wick in for at least 24 hours and keep it moist by adding 3 to 5 drops of Acetic Acid every 4 to 6 hours. The wick may be removed after 24 hours. Continue to instill 3 - 5 drops of acetic acid 3 or 4 times daily thereafter, for as long as indicated. ($)
  • Acetic acid and hydrocortisone solution (Vosol HC®, Acetasol HC®) - insert a wick of cotton saturated with acetic acid into the ear canal. Keep the wick in for at least 24 hours and keep it moist by adding 3 to 5 drops of acetic acid every 4 to 6 hours. The wick may be removed after 24 hours. Continue to instill 3 - 5 drops of acetic acid 3 or 4 times daily thereafter, for as long as indicated ($$)
  • Ciprofloxacin and dexamethasone (Ciprodex®) - Four drops instilled into the affected ear twice daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward. This position should be maintained for 60 seconds. ($$)
  • Ciprofloxacin and hydrocortisone (Cipro HC®) - For children (age 1 year and older) and adults, 3 drops of the suspension should be instilled into the affected ear twice daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 30-60 seconds to facilitate penetration of the drops into the ear. ($$$$)
  • Cortisporin Otic® (neomycin, polymyxin b, hydrocortisone) - otic solution; 3 - 4 drops in affected ear 3 - 4 times a day. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 5 minutes to facilitate penetration of the drops into the ear canal. Do not use for more than 10 days. ($)
  • Cortisporin-TC® (colistin, neomycin, thonzonium, hydrocortisone) - otic suspension; 4 - 5 drops in affected ear 3 - 4 times a day. The patient should lie with the affected ear upward and then the drops should be instilled. This position should be maintained for 5 minutes to facilitate penetration of the drops into the ear canal. Do not use for more than 10 days. ($$$$)
  • Finafloxacin otic suspension (Xtoro®) - For children (age 1 year and older) and adults, instill four drops into the affected ear(s) twice daily for seven days. Warm bottle by holding in hand before use. Shake bottle well. Lie with the affected ear upward, instill the drops, and maintain the position for 60 seconds to facilitate penetration of the drops into the ear canal. ($$$$)
  • Ofloxacin (Floxin otic®)
    • Pediatric (from 6 months to 13 years old) - Five drops instilled into the affected ear once daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward, and then the drops should be instilled. This position should be maintained for five minutes. ($)
    • Patients ≥ 13 years - Ten drops instilled into the affected ear once daily for seven days. Warm bottle by holding in hand before use. The patient should lie with the affected ear upward, and then the drops should be instilled. This position should be maintained for five minutes. ($)

Pulpitis (Toothache)

Overview

Definitions
  • Pulpitis - the tissue inside the tooth is called the pulp, and it contains nerves, blood vessels, and connective tissue. Pulpitis is inflammation of the pulp, and the most common cause is an infection (see tooth anatomy illustration and pulpitis illustration).
  • Periodontitis - periodontitis is an infection of the gums, and apical periodontitis is an infection of the tissue around the tip of the tooth root
Treatment overview
  • Dentists treat pulpitis with a pulpotomy (removal of crown material and replacement with filler), pulpectomy plus root canal (removal of the crown and root material and replacement with filler), or extraction if the tooth is not salvageable. Primary care providers can't offer these therapies, so they often prescribe antibiotics instead. No large, randomized controlled trial has evaluated the effects of this common practice. A small trial (N=40) that compared penicillin to placebo in patients with irreversible pulpitis found no benefit of penicillin for pain control. [PMID 11077389]
  • The American Dental Association (ADA) 2019 pulpitis guidelines state that antibiotics are "adjunct to definitive, conservative dental treatment" in patients who have systemic symptoms. Drug recommendations from those guidelines are provided below. [13,21]

Treatment (ADA 2019)

Non-penicillin allergic
  • First-line
    • Amoxicillin 500 mg three times a day for 3 - 7 days ($)
  • Second-line
    • Pen VK 500 mg four times a day for 3 - 7 days ($)
  • Treatment failure
    • Add metronidazole 500 mg three times a day for 7 days OR
    • Augmentin 500/125 mg three times a day for 7 days ($)
Penicillin allergic
  • No history of serious reaction✝
    • Cephalexin 500 mg four times a day for 3 - 7 days ($)
  • History of serious reaction✝ (one of the following)
    • Azithromycin 500 mg on day 1 followed by 250 mg for 4 additional days ($)
    • Clindamycin 300 mg four times a day for 3 - 7 days ($)
  • Treatment failure
  • ✝ Serious reaction defined as history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin

Studies


Thrush (oral candidiasis)

Overview

  • Thrush is caused by an overgrowth of Candida sp, most commonly C albicans. Risk factors for thrush include advanced age, dentures, diabetes, immunocompromised state (e.g. HIV/AIDS, cancer, chemotherapy), steroid inhalers, antibiotic use, Cushing's syndrome, salivary gland dysfunction (e.g. Sjögren's syndrome, radiation to the head and neck) nutritional deficiencies, high carbohydrate diet, and smoking.
  • Other conditions that can present as white patches in the mouth include lichen planus, squamous cell carcinoma, lichenoid reaction, and leukoplakia. One distinguishing feature of thrush is that the lesions can be scraped off to expose underlying erythema.
  • Patients with thrush should practice good oral hygiene, including regular brushing of the teeth, gums, and mouth, cleaning and soaking dentures, and removing dentures at night
  • Topical therapy is usually effective, and systemic therapy is rarely needed [20]

Treatment

Pediatric
  • Infants
    • Nystatin suspension 100,000 units/ml - 2 ml (200,000 units) four times a day. Place 1 ml in each side of mouth and avoid feeding for 5 - 10 minutes. Continue treatment for at least 48 hours after lesions have disappeared. ($)
  • Children
    • Nystatin suspension 100,000 units/ml - 4 - 6 ml (400,000 - 600,000 units) four times a day. Solution should be swished and swallowed. Retain in mouth as long as possible. Continue treatment for at least 48 hours after lesions have disappeared. ($)
Adults
  • Clotrimazole troche (Mycelex®)
    • Active infection - place one troche (10 mg) in mouth and allow to dissolve five times a day for 14 days ($-$$)
    • Prophylaxis (e.g. chemo, radiation) - place one troche (10 mg) in mouth and allow to dissolve three times a day for duration of therapy ($+)
  • Miconazole (Oravig®) - apply one buccal tablet (50 mg) to the upper gum once daily for 14 days ($$$$)
  • Nystatin suspension 100,000 units/ml - 4 - 6 ml (400,000 - 600,000 units) four times a day. Solution should be swished and swallowed. Retain in mouth as long as possible. Continue treatment for at least 48 hours after lesions have disappeared. ($)


Pricing legend
  • $ = 0 - $50
  • $$ = $51 - $100
  • $$$ = $101 - $150
  • $$$$ = > $151
  • Pricing based on one month of therapy at standard dosing in an adult
  • Pricing based on information from GoodRX.com®
  • Pricing may vary by region and availability